Scholarship Application

1
Let us know some basics* This field is required.
[LEGAL] FIRST NAME
[LEGAL] LAST NAME
PREFERRED NAME
DATE OF BIRTH [mm-dd-yyyy]
EMAIL ADDRESS
PHONE NUMBER including area code
2
Let us know some basics* This field is required.Cont.
CITY WHERE YOU WERE BORN
STATE [or country] WHERE YOU WERE BORN
CURRENT CITY YOU LIVE IN
CURRENT STATE YOU LIVE IN
Please Select
Please Select
PLEASE SELECT ONE
FEMALE
MALE
NON-BINARY
OTHER
GENDER
Please Select
Please Select
PLEASE SELECT ONE
US CITIZEN
US RESIDENT
NON-IMMIGRANT
UNDOCUMENTED IMMIGRANT
IMMIGRANT STATUS
ANNUAL HOUSEHOLD INCOME [Proof of income may be requested when reviewing applications.]
3
Tell us about your education* This field is required.
NAME OF YOUR CURRENT SCHOOL
CITY, STATE of your current school
GPA (Weighted and Un-Weighted)
EXPECTED MAJOR(S)
SCHOOLS YOU'RE APPLYING FOR (List your top 3)
4
Would you please tell us a little about your diagnosis?* This field is required.
DATE OF CANCER DIAGNOSIS [mm-yyyy]
CITY, STATE OF YOUR DIAGNOSIS
HOSPITAL NAME WHERE YOU WERE DIAGNOSED
TYPE(S) OF CANCER DIAGNOSED WITH
ANYTHING ELSE YOU WOULD LIKE TO SHARE
5
Upload Your Essay* This field is required.Upload a PDF copy of your essay that includes the following: ⬥ In no less than 750 words, share your cancer story with us. ⬥ How did it affect you and your family? ⬥ Did you focus on education, hobbies, family, etc. to help? ⬥ How did your story encourage you to pursue higher education? ⬥ What are your future educational, personal, and career goals?
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